We must stop blaming ‘systems’ for shameful human failures
Opinion: In Ireland, scandals and disasters are never anybody’s fault
In the horse meat scandal and others, the buck should have stopped somewhere; someone was responsible. Photographer: Mario Proenca/Bloomberg via Getty Images
Once again, this time in the case of the death of Savita Halappanavar, a “systems failure” has been put forward to explain shortcomings in her treatment.
Expert witness Dr Peter Boylan, who carried out a review of the clinical notes in the case, concluded that Savita’s life could have been saved were it not for the legal prohibition on terminating her pregnancy earlier and that the failure to monitor vital signs, follow up on blood tests and the litany of other other clinical lapses did not individually cause her death.
That distinction having been made, practically every witness and commentator acknowledged that these breaches of good practice, poor communication among the clinicians, administration of an inadequate antibiotic and the entry of notes into the file long after the event were entirely unacceptable.
It is the resort to the “systems failure” explanation for these shameful breaches of the most basic standards that I want to address here.
The “systems failure” explanation has been used repeatedly in recent years in Ireland as a convenient fig leaf to enable individuals who were ultimately responsible for catastrophic institutional crashes in all sectors and individual human tragedies to escape accountability. Hundreds of children died in the care of the State because of “systems failure”. Banks collapsed, people died of hospital-acquired infections, families in Priory Hall had to be evacuated from their dangerous and now almost worthless properties – and so on, and all because of “systems failure”.
Whenever “systems failure” is cited as the explanatory cause of a disaster, the rider is by implication added, “so no one is to blame”. For example, two years ago when the Government was under pressure over its promotion of Kevin Cardiff from secretary general of the Department of Finance to a senior position in the European Court of Auditors, Minister for Finance Michael Noonan said “it is wrong to start blaming someone, it was a systems failure that caused the error”. Cardiff was not personally responsible for a €3.5 billion accounting mistake; it occurred at a lower, operational level.
Whenever there is a “systems failure”, however, it does not mean that no one is to blame, because the vital question always arises: who was responsible for the design, installation, maintenance, auditing and continuous improvement of the system in question? So, for example, if a train was derailed because a humble rail worker failed to tighten the bolts that hold the tracks in place, that worker would not be responsible, accountable and liable if it turned out that he had never been trained to do the job properly and was never supervised. In such a case it would be the board or some senior manager(s) who should be held accountable and deemed culpable, since they had not put in place a robust safety system, and that is what they are handsomely paid to do.
In numerous cases such as corporate governance issues at Fás, past failures by the financial regulator, the horse meat scandal and others, the buck should have stopped somewhere; someone was responsible, the senior management, the board or sometimes the relevant minister.
Boards and senior managers are responsible not just for achieving certain business outcomes, they are also responsible for the overall health of their organisation, which includes ensuring it has structures that are fit for purpose; embedded operational, HR, safety and other systems that reflect best practice; a culture that exhibits the highest standards in all matters; and other vital elements , not least ensuring that the necessary skills are in place. A spate of inquiries to the Department of Finance since 2008 revealed a dearth of mission-critical skills in banking, economics and statistics. It was like trying to run a hospital without clinical specialists and, while some progress has been made on this front, there is still a long way to go.
A few weeks ago, for example, the EU-IMF troika reminded the Health Service Executive, again, to strengthen its financial skills, and our own fiscal council identified numerous weaknesses in the tools still being used by the Department of Finance.
The time has come to ban from all reports on costly and tragic events the recourse to “systems failure” as the ultimate explanation for what went wrong, unless, that is, there is an obligatory additional chapter on th failure of senior managers , boards and government ministers in allowing degraded, corrupt or non-existent systems to prevail on their watch.
When Praveen Halappanavar was asked if the full truth had been revealed, he said ,“no ... I still don’t know why my wife died ... I still don’t know who was responsible”. Someone was, and it wasn’t some disembodied, fatherless “system”.
Dr Eddie Molloy is a management consultant
* This article was amended on May 24th, 2013, for legal reasons.